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Sports Medicine Research Laboratory The University of North Carolina at Chapel Hill Identification of Risk Factors for ACL Injury and Re-Injury Darin A.

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Presentation on theme: "Sports Medicine Research Laboratory The University of North Carolina at Chapel Hill Identification of Risk Factors for ACL Injury and Re-Injury Darin A."— Presentation transcript:

1 Sports Medicine Research Laboratory The University of North Carolina at Chapel Hill Identification of Risk Factors for ACL Injury and Re-Injury Darin A. Padua, PhD, ATC Director, Sports Medicine Research Laboratory College of Arts & Sciences Department of Exercise & Sport Science 8 th Annual Steadman Hawkins Sports Medicine Symposium

2 Overview Prospective risk factors for ACL injury –JUMP-ACL study findings Potential risk factors for ACL re-injury –Same as incident ACL injury? Implications for ACL injury prevention and return to participation decision making

3 How can we avoid ACL injury / re-injury? 3 Keys to Improving: 1.Understand risk factors for injury / re-injury 2.Systematic exercise progression –Focus on modifying risk factors 3.Systematic return to play criteria –Based on successful modification of risk factors

4 5 year trial at each academy 400 / academy / year –~40% female –~6,000 subjects –15,000 man-years Goal = Capture primary ACL injuries

5 Jump-Landing Task Drop height = 30 cm Horizontal distance = 50% body height Jump for maximum vertical height immediately after landing Collected 3-D joint kinematics & kinetics –Electromagnetic system & force-plate

6 Hip ExtensionHip Abduction Hip External Rotation Hip Internal Rotation Knee FlexionKnee Extension Strength Testing

7 Postural Alignment Testing Q-Angle Navicular Drop

8 No Yes nPct n Females2,39539%3940% Males3,63161% 5960% Total6,026100% 98100% Non-Contact / Indirect Contact Primary ACL Injuries Key Findings

9 Knee Flexion Angle Knee Varus(+) / Valgus(-) Knee IR(+) / ER(-) Knee Flexion No difference in knee flexion kinematics Both groups land with small knee flexion Knee Valgus ACL injured land in valgus position No difference in peak knee valgus Knee Rotation No difference in knee rotation ---- ACL Injured ---- Healthy

10 Hip Flexion (-) Hip IR(+) / ER(-) Hip Adduction(+) / Abduction(-) Hip Flexion Both groups land with small knee flexion ACL injured demonstrate greater peak flexion Hip Adduction ACL injured land in more adducted position Hip Rotation ACL injured land in more externally rotated position ---- ACL Injured ---- Healthy

11 “Prospective Profile” of ACL Injured ↓ Knee Flexion ↑ Knee Valgus (Initial Contact) ↑ Hip External Rotation ↑ Hip ADDuction ↑ Hip Flexion (Displacement) ↑ Ext. Knee Valgus Moment ↓ Hip Flexion ↓ Flexion at Initial Contact Altered Knee Valgus Mechanics Altered Hip Neuromuscular Control

12 NOTE This is NOT a study of injury mechanisms –No-one tore their ACL during testing This is a study that helps us: –Identify and screen-out individuals with high- risk movement patterns –Many years prior to injury

13 Some findings agree with non-contact ACL injury mechanisms -- some do not ↓ Knee Flexion ↑ Knee Valgus (Initial Contact) ↑ Hip External Rotation ↑ Hip ADDuction ↑ Hip Flexion (Displacement) ↑ Int. Knee Varus Moment (Ext. Valgus) ↓ Hip Flexion Ireland, 1998

14 ACL Loading ACL Stopping Cutting Jump-Landing Multiple Factors Affect ACL Loading

15 High Risk Movement Pattern Low Risk Movement Pattern ACL Loading Multiple Factors Affect ACL Loading

16 High Risk Movement Pattern Low Risk Movement Pattern ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing

17 High Risk Movement Pattern Low Risk Movement Pattern ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing

18 High Risk Movement Pattern Low Risk Movement Pattern ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing

19 High Risk Movement Pattern Low Risk Movement Pattern ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing

20 High Risk Movement Pattern Low Risk Movement Pattern ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing

21 Low Risk Movement Pattern ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing High Risk Movement Pattern

22 Low Risk Movement Pattern ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing High Risk Movement Pattern

23 ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing Misjudgement Distracted Defender Moves Foot Slips Pushed

24 ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing Misjudgement Distracted Defender Moves Foot Slips Pushed

25 ACL Loading Multiple Factors Affect ACL Loading Misjudgement Foot Slips Pushed Stopping Cutting Jump-Landing Distracted Defender Moves

26 ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing High Risk Movement Pattern Misjudgement Distracted Defender Moves Foot Slips Pushed

27 ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing High Risk Movement Pattern Misjudgement Distracted Defender Moves Foot Slips Pushed

28 ACL Injury ACL Loading Multiple Factors Affect ACL Loading Stopping Cutting Jump-Landing High Risk Movement Pattern Misjudgement Distracted Defender Moves Foot Slips Pushed

29 How can this information provide insight into rehabilitation and return to participation decisions in ACL injured?

30 Previous History of ACL Surgery Non-Contact / Indirect Contact ACL Injury (excluded Direct Contact) N=150 Prior ACL Inj. 13 re-injuries (8.7%) N=5,758 No ACL Inj. 78 primary injuries (1.4%) No ACL Inj. Prior ACL Inj. Rate Ratio= 6.9; 95%CI: 3.8, 12.4; p<0.01

31 Q: Bad Workmanship or Biomechanics? A: Bad Biomechanics ACL Re-injuries in Prior ACL InjuredACL Re-injury Side Prior ACL Injury SideLeftRight Left33 Right22 Both11 Total66 Equal risk for ipsilateral and contralateral sides

32 No Injury History Primary ACL Injury Prior ACL Injury  Knee flexion motion

33  Knee valgus at IC No Injury History Primary ACL Injury Prior ACL Injury

34  Hip Flexion at IC  Hip Flexion Motion No Injury History Primary ACL Injury Prior ACL Injury

35  Hip ER at IC No Injury History Primary ACL Injury Prior ACL Injury

36  Hip ADDuction at IC No Injury History Primary ACL Injury Prior ACL Injury

37  Knee Extension Moment No Injury History Primary ACL Injury Prior ACL Injury

38 ↓ Knee & Hip Flexion IC ↑ Knee Valgus IC ↑ Hip Adduction ↑ Hip ER ↑ Hip Flexion Motion Movement Patterns Healthy ≠ ACL injured (primary & prior) Primary ACL Injury = Prior ACL Injury No Injury History Primary ACL Injury Prior ACL Injury ↑ Knee Flexion Motion ↑ Hip Flexion IC

39 Causation or Compensation? ↓ Knee Flexion ↑ Knee Valgus (Initial Contact) ↑ Hip External Rotation ↑ Hip ADDuction ↑ Hip Flexion (Displacement) ↑ Ext. Knee Valgus Moment ↓ Hip Flexion ↑ Hip Flexion (Initial Contact) ↑ Knee Flexion (Displacement) ↓ Int. Knee Extension Moment Prior to Initial Injury (causation) After Initial Injury (compensation)

40 Compensatory Movement Pattern Development  Quadriceps Function –  Strength (Palmieri-Smith et al, 2008; Ingersoll et al, 2008) –  Activation (Hart et al, 2008; Ingersoll et al, 2008) –  Extension moment (Hart et al, 2010; Ingersoll et al, 2008) ↑ Hip Flexion (Displacement) ↓ Int. Knee Extension Moment ↑ Hip Flexion (Initial Contact) After Initial Injury (compensation)

41 Normal Quadriceps Function Quadriceps Dysfunction Compensation ↑ Knee Flexion (Displacement) ↓ Int. Knee Extension Moment ↑ Hip Flexion (Initial Contact)

42 Implications Prevention Prevention of ACL injury / re-injury may be possible by modifying high risk movements Rehabilitation Movement quality should be part of exercise progression & return to participation criteria –Returning to pre-injury status is NOT sufficient

43 Quality Movement Matters  Faulty movement patterns   Functional outcomes & performance (Trulsson et al, 2010) –Battery of 9 movement tasks: 1)Single leg bridge6) Stand from half-kneeling 2)Weight shift7) Forward lunge 3)Single leg squat8) Backward walking (t-mill) 4)Single leg heel raise9) Double leg squat 5)Single leg balance on unstable surface

44 Quality Movement Matters  Risk of second ACL injury (Paterno et al, 2010) –Hip IR moment (uninvolved leg) (8x) –  Frontal plane knee motion (involved leg) (3.5x) –Asymmetrical knee extension moment (3x) –  Single leg postural stability (involved leg) (2x) 3D biomechanical analyses is best determinant of readiness for return to play –Sensitivity = 92% –Specificity = 88%

45 Key Points Previous ACL injury history = Risk factor Similar risk factors for ACL injury and re-injury –Faulty movement patterns Important factors for successful return to play –Restore quadriceps function –Achieve “excellent” movement quality –Return to pre-injury/uninjured side status is not sufficient Faulty movement patterns pre-disposed to initial injury

46 Thank You

47 JUMP - ACL Research Team UNC Chapel Hill Steve Marshall, PhD Darin Padua, PhD, ATC Sue Wolf, RN Shrikant Bangdiwala, PhD Bing Yu, PhD Charles Thigpen, PhD, PT, ATC Michelle Boling, PhD, ATC Ben Goerger, MS, ATC Sarah Knowles, PhD Collaborators: William Garrett, MD, PhD (Duke) Barry Boden, MD (Ortho Cntr) Marjorie King, PhD, ATC, PT (PSU) Brent Arnold / Scott Ross (VCU) USUHS Anthony Beutler, MD USNA Marlene DeMaio, MD Scott Pyne, MD Greg Calhoon, ATC USAFA John Tokish, MD Keith Odegard, MD USMA Dean Taylor, MD Paul DeBeradino, MD Steve Slovoda, MD Kenneth Cameron, PhD, ATC Sally Mountcastle, PhD Jennifer Jones, Med, ATC

48 Acknowledgements Grant #R01-AR

49 The ACL Injury Problem Disability: –77% sports disability in 5 yrs –44% disability with ADL’s in 5 yrs –Increase Risk of Knee Osteoarthritis No Surgery: >90% in 20 years “Good” Surgery: >90% in 20 years

50 ACL Injury Rehab. & Return to Play: What’s the big deal? Re-Injury Rate (RIR) (Overall / General Pop.) Wright et al (2 year f/u) = 3% Salmon et al (4 year f/u) = 6% Shelbourne et al (5 year f/u) = 9.6% Pinczewski et al (10 year f/u) = 22% to 33% –ACL graft or contra-lateral ACL injury

51 Factors Influencing Re-Injury Rate Gender –Males = Females (Shelbourne et al, 2009) Timing of Return to Play (RTP) –RTP 6 mos (Shelbourne et al, 2009) –  RIR with RTP < 7 mos + high demand activity (Laboute et al, 2010) Sport Type / Physical Activity Level –  RIR in high demand activity (pivoting, cutting, landing, jumping) (Laboute et al, 2010; Shelbourne et al, 2009) –  RIR in basketball (52%) (Shelbourne, 2009) Soccer (15%) and other sports (6.6%)

52 Who is at greatest risk for ACL injury? High Risk Profile: RTP < 7 months High demand sports (basketball) Young (18-20 yrs) Males ACL Injury Incidence General Pop. = 1 injury per 2,200 people (0.0004% injury rate) High Risk Profile = 10.6 to 13.9% injury rate (>1,000x increased risk)

53 Quadriceps Dysfunction Exacerbate faulty movement patterns associated with initial injury risk –  Hip Flexion (Anterior Pelvic Tilt) ↑ Knee Valgus (Initial Contact) ↑ Hip External Rotation ↑ Hip ADDuction ↑ Hip Flexion (Displacement) ↑ Int. Knee Varus Moment (Ext. Valgus)

54 ↑ Pelvo-Femoral Flexion (Anterior Pelvic Tilt) Superior Migration of Posterior Pelvis ↑ Length of GMAX & Hamstrings ↓ Force Production ↑ Reliance on synergistic hip extensor muscles to decelerate hip flexion Alters mechanical function of hip musculature

55 Hip FlexionHip Extension GMED post. GMAX Hamstrings ADD Magnus GMIN ant. IP TFL Sartorius Rectus Femoris ADD Brevis ADD Longus Gracillis Pectineus Neumann, JOSPT 2010

56 ↑ Pelvo-Femoral Flexion Reversal of Lever Arm (direction of pull) Hip ADDuctors (except adductor magnus, already hip extensor) – ↑ Hip Flexion → Extension lever arm Neumann, JOSPT 2010

57 Hip FlexionHip Extension GMED post. GMAX Hamstrings ADD Magnus GMIN ant. IP TFL Sartorius Rectus Femoris ADD Brevis ADD Longus Gracillis Pectineus Neumann, JOSPT 2010

58 Hip FlexionHip Extension GMED post. GMAX Hamstrings ADD Magnus GMIN ant. IP TFL Sartorius Rectus Femoris ADD Brevis ADD Longus Gracillis Pectineus Synergistic Dominance ↓ ↑ Hip ADDuction Moment Neumann, JOSPT 2010

59 ↑ Pelvo-Femoral Flexion Reversal of Lever Arm (direction of pull) Hip External Rotators (piriformis, gluteus medius – post, gluteus maximus – ant) – ↑ Hip Flexion → Internal Rotation lever arm Increase of Lever Arm (M = F * d) Dramatically increases the lever arm of hip internal rotators – ↑ Hip Flexion → ↑ Internal Rotation lever arm

60 Hip External Rotation Hip Internal Rotation GMIN ant. GMED ant. Pectineus ADD Longus ADD Brevis Obturator ext. GMED post. GMIN post. Quadratus Femoris Gemellus sup. Obturatur int. Gemellus inf. Piriformis GMAX Neumann, JOSPT 2010

61 Hip External Rotation Hip Internal Rotation GMIN ant. GMED ant. Pectineus ADD Longus ADD Brevis Obturator ext. GMED post. GMIN post. Quadratus Femoris Gemellus sup. Obturatur int. Gemellus inf. Piriformis GMAX Neumann, JOSPT 2010

62 Hip External Rotation Hip Internal Rotation GMIN ant. GMED ant. Pectineus ADD Longus ADD Brevis Obturator ext. GMED post. GMIN post. Quadratus Femoris Gemellus sup. Obturatur int. Gemellus inf. Piriformis GMAX ↑ Hip Internal Rotation Moment

63 Quadriceps Dysfunction Post ACL Injury ↑ Hip Flexion (IC) (Ant. Pelvic Tilt) ↑ Length of GMAX & HAMS Synergistic Dominance Alters Mechanical Function Alters Length- Tension → ↓ Force Hip ADD Direction Change & ↑ Leverage Hip ER Hip IR ↑ Knee Valgus (Initial Contact) ↑ Hip External Rotation ↑ Hip ADDuction ↑ Hip Flexion (Displacement) ↑ Ext. Knee Valgus Moment Compensatory Movement Patterns Exacerbate Faulty Movement Patterns ↓ Int. Knee Extension Moment ↓ ↑ Knee Flexion Displacement


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